The concepts and use of quality improvement are not new to public health, but precise enumeration of quality improvement activities in public health has been problematic. Further, the context for, and advancement of, quality improvement in public health is still being defined. Nevertheless, quality improvement, along with voluntary accreditation, is critical to improving the performance of state and local public health agencies.
In the 2008 profile of local health departments, 55 percent reported conducting quality improvement activities. If these activities are to move beyond sporadic, one-time applications, all strategies in the ecological framework suggested in this article, must be implemented. In particular, strategies to train and engage public health leaders as champions for quality improvement and supporters of a quality improvement culture need to be created and implemented.